A 50 year old female withe fever and pain abdomen
January 12,2022
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
K. Teja sree
Rollno 54
9th semester
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan
(All the information have been collected from patient and her daughter in law)
Case discussion;
(Following is the view of my case) ;
Chief complaints
A 50 year old female patient, paddy field worker by occupation brought to casuality on 11/1/22(10;30pm) with
complaints of abdominal pain and
fever since 5days.
Shortness of breath since 1day.
History of present illness;
The patient was apparently asymptomatic 5 days ago. then she had fever with high grade
which was insidious in onset, gradually progressive.intermittent in nature and associated with evening rise of temperature
Fever was not associated with chills and rigor.and was relieved on taking by medication which was prescribed by local rmp
C/O pain in right hypochondrium and epigastrium since 5days.which was sudden in onset and gradually progressive.radiating to shoulder.it was dull aching type. Aggrevated on working and relieved on rest or medication
Since on 11/1/22 abdominal pain was severe with shortness of breath due to which she visited local rmp .and she was referred to our hospital.
C/O shortness of breath since 1day grade -2
No history of vomiting,loose stools,weight loss.,chest pain, palpitations,pedal edema
No h/O outside food intake
Past history;
No history of similar complaints inthe past.
She is not a known case of diabetes, hypertension, tuberculosis, asthma and thyroid ,epilepsy disorders
Family history; insignificant.
Personal history;
Appetite; decreased since 4 days
Diet; mixed
Bowel and bladder ; regular,
Sleep; adequate
Addictions; occasional toddy drinker .
General examination;
The patient is conscious , coherent and cooperative. Well oriented to time place person.
Pallor ; absent
Icterus ; mild
Cyanosis; absent
Clubbing ; absent
Lymphadenopathy; absent
Edema ; absent.
Vitals;
Temperature; febrile(99.6° f)
Blood pressure: 120/80 mmHg
Heart rate : 90bpm
Respiratory rate: 22cpm
Spo2: 97%on RA
RBS- ; 85mg/dl
Temperature chart:
Systemic examination;
Abdomen ;
Shape; slightly distended
Umbilicus; central
Movements ; normal
No visible pulsations,or engorged veins,no visible peristalsis
Skin over abdomen ; normal
Palpation :
Tenderness in right hypochondrium and epigastrium,local rise of temperature present
Hepatomegaly present
No splenomegaly
Percussion;
Liver : dull note heared
No shifting dullness or fluid thrills
Auscultation ; bowel sounds are heared
Respiratory system ;
Inspection;
Inspection of upper respiratory tract;
Oral cavity ; normal
Nose: no dns,polyp
Pharynx; normal
Lower respiratory tract;
Position of apex beat ; left 5 ICS 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movements of chest ; normal
Position of trachea ; midline
Bilateral air entry present
Palpation:
No tenderness over chest wall,no crepitations,no palpable added sounds,no palpable pleural rub
Percussion;
Resonant note heared
Auscultation; normal vesicular breath sounds heared, bilateral air entry present
Cardiovascular system;
Cranial nerves;
1 ) olfactory nerve ; percieves smell
2) optic nerve : normal visual acuity
3) occlomotor nerve ; normal
4) trochlear nerve ; normal
5) trigeminal nerve ; normal
6) abducens nerve ; normal
7) facial nerve; normal
8) vestibuli cochlear nerve; normal
9) glossopharyngeal nerve; normal
10)vagus nerve ; normal
11) spinal accessory nerve ; normal
12) hypoglossal nerve ; normal
Gait: normal
Motor system ;
Power U/L L/L
Right 5/5 5/5
Left 5/5 5/5
Tone U/L L/L
Right normal. Normal
Left Normal Normal
Reflexes Biceps triceps supinator knee ankle
Right 2+ 2+ 2+ 2+. 2+
Left 2+ 2+. 2+. 2+. 2+
Plantar reflex: flexor
Sensory system : normal
Cerebellar signs;
Finger nose in coordination; yes
Knee heel in coordination; yes
Investigations;
On12/1/22;
Serology;
Rapid antigen test: negative
RT PCR
Hemogram;
Hemoglobin ; 11.3g/dl
Total leucocyte count; 30,500cells /cumm
Platelet count ; 2.65 lakhs/cumm
Renal function tests;
Urea- ; 73 mg/ dl
Creatinine : 1.7 mg/ dl
Sodium ; 137
Potassium : 4.2
Chloride ; 95
Liver function tests;
Total bilirubin ; 2.55
Direct bilirubin ; 1.08
SGOT : 41
SGPT : 37
ALP; 1022
Total protein : 5.9
Albumin; 1.72
A/G ratio :0.41
RBS- ;70
ECG ;
Ultrasound; (11/1/22)
Liver; increased size- e/o 9.3×8.8cms
Large heteroechoic lesion in liver parenchyma of right lobe in segments 6and 7 , with no vascularity
( No intervening liver parenchyma between liver capsule and lesion)
* Right mild pleural effusion with air sonograms in the basal lung segments.
Impression;
1) liver abscess with poor liquefaction (15-20%) with hepatomegaly
2) Right mild pleural effusion with consolidatory changes in underlying lung segments.
3)Raised echogenicity of bilateral kidneys.
On 12/1/2022
Mild ascites
Provisional diagnosis;
liver abscess
Treatment ;
1) Inj CEFTRIAXONE 2gm /iv/bd
2) Inj metrogyl 750mg /iv/TID
8am- 11am- 8pm
3)Inj PAN 40 mg / iv/ od
1-0-0
4) Inj Tramadol 1 amp in 100ml na/ iv / sos
5)Inj zofer 4mg / iv/ bd
1-0-1
6) intravenous fluids - NS, RL, Dns- 100 ml
7) strict intra oral charting
8) Inj neomol 1gm/iv/ sos
